7.
Epidemiology
3% of all cases of abdominal pain admitted to
hospital.
40 cases per year per 100,000 adults.
[International]
Ranges between 5 and 80 per 100,000 population
The highest incidence recorded in the United
States and Finland
In 80% of cases: mild and resolves without
serious prob.
Sex No predilection exists.
Age- 35-64 years
Dr. Afzal

15.
Typical signs if necrosis
Cullen sign (bluish discoloration around the
umbilicus resulting from hemoperitoneum)
Grey-Turner sign (reddish-brown discoloration along
the flanks resulting from retroperitoneal blood
dissecting along tissue planes); more commonly,
patients may have a ruddy erythema in the flanks
secondary to extravasated pancreatic exudate
Erythematous skin nodules, usually no larger than 1
cm and typically located on extensor skin surfaces;
polyarthritis
Dr. Afzal

24.
Treatment guidelines
The guidelines recommend against routinely using
prophylactic antibiotics in cases of severe acute
pancreatitis and/or sterile necrosis; however,
intervention in patients with infected necrosis may be
delayed through the use of antibiotics that penetrate
the necrosis
In mild cases of acute pancreatitis with no nausea and
vomiting, oral feeding can be initiated immediately;
Enteral nutrition should be used in severe cases to
prevent infectious complications, and parenteral
nutrition should be avoided
Dr. Afzal

30.
Pain control
Patient controlled analgesia: opioids
Fentanyl better, safety profile, especially in renal
impairment.

Bolus regimen ranges from 20 to 50 micrograms with a 10minute lock-out period (time from the end of one dose
infusion to the time the machine starts responding to
another demand).
Alternate:
 Parenteral meperidine (50 to 100 mg) every 3 to 4 hours. less spasm
of the sphincter of Oddi. not as effective as other opioids ,
contraindicated in renal failure.
 Parenteral morphine 10-15 mg iv , cause spasm of the sphincter of
Oddi, increase serum amylase and rarely pancreatitis.
 Hydromorphone, longer half-life than meperidine, parenterally by
a patient-controlled analgesia (PCA) pump.

Dr. Afzal

32.
Antibiotics are not recommended
Prophylactic antibiotics
20 percent of patients develop an extra-pancreatic infection
 bloodstream infections,
 Pneumonia
 urinary tract infections

Administer antibiotic according to site and C/S report
If severe necrotizing AP:
 Broad-spectrum antibiotics:
Start within the first 48 hours and continued for 2 to 3 weeks.
 IMIPENEM-CILASTATIN (500 mg every 8 hours) may be most
effective
 Ciprofloxacin, Levofloxacin) with metronidazole should be
considered for penicillin-allergic patients

Antifungal:
Prophylactic antifungal therapy not recommended
occur in approximately 9 percent of necrotizing pancreatitis.
However, it is not clear if they are associated with higher
mortality
Dr. Afzal

33.
Miscellaneous
Protease inhibitors: anti trypsin
DROTRECOGIN ALFA may benefit patients with
pancreatitis and systemic inflammatory response syndrome
 Recombinant form of human activated protein C that has anti-
thrombotic, anti-inflammatory, and pro-fibrinolytic properties.
 Used mainly in intensive care medicine as a treatment for severe
sepsis
Octreotide, 0.1 mg subcutaneously every 8 hours, decrease sepsis,
length of hospital stay, and mortality
Morbidity did not differ significantly between the groups. This study did not demonstrate an
inhibitory effect of octreotide on exocrine pancreatic secretion. Based on these results, the
routine use of octreotide after PD cannot be recommended: HPB (Oxford). 2013
May;15(5):392-9
Insulin if hyperglycemia.
surgical intervention in severe necrotizing pancreatitis.
Dr. Afzal

34.
IMPORTANT
 During the FIRST TWO weeks after a SEVERE ATTACK
 Intensive critical care (ICU):

To support the cardiopulmonary (heart and lung), liver and kidneys
that may fail due to RELEASE OF LARGE AMOUNTS TOXINS FROM
THE DEAD PANCREAS in the abdomen.

Almost all patients require intravenous nutrition.
 Surgical treatment for severe acute pancreatitis
 Only in a tertiary medical center by experienced surgeon
pancreatitis
Dr. Afzal

35.
Complications in Acute pancreatitis
Local complications
 Pancreatic necrosis -Infected necrosis is almost always fatal without
intervention
 Acute Fluid Collections are common in patients with severe
pancreatitis (occurring in 30%-50%).
 Pancreatic abscess is a collection of pus adjacent to pancreas
presenting several months after attack.
 Acute pseudocyst rupture or haemorrhage in pseudocyst.
 Pancreatic ascites occurs when a pseudo-cyst collapses into peritoneal
cavity or major pancreatic duct breaks down and releases pancreatic
juices into peritoneal cavity.

42.
Clinicalpain, malabsorption, weight loss, and diabetes. Jaundice occurs
Presentation
 Abdominal
in about 10% of patients.
 PAIN:
 dull epigastric or abdominal pain
 radiates to the back.
 consistent or episodic
 deep-seated,
 positional,
 frequently nocturnal
 unresponsive to medication
 Nausea and vomiting often accompany the pain.
 Severe attacks last from several days to weeks
 aggravated by eating and relieved by abstinence from alcohol.
 Steatorrhea (excessive loss of fat in the feces) with diarrhea and bloating
 Azotorrhea (excessive loss of protein in the feces) are seen in most patients.
 Weight loss may occur.
 Diabetes usually a late due to pancreatic calcification.
 Neuropathy is sometimes seen.
Dr. Afzal